Integrated Chronic Pain Treatment and Training Project
- Need: To reduce prescription opioid misuse and overdoses in North Carolina.
- Intervention: The ICPTTP standardizes and streamlines chronic pain management in primary care clinics.
- Results: The ICPTTP has reduced patients' average daily morphine equivalent dose, and 25% of program participants have stopped taking opioids altogether.
Promising (About evidence-level criteria)
In 2015, 1,567 North Carolinians died from drug overdoses. The state lost 1,358 more lives in 2014 and 1,259 more in 2013. Some of these deaths come from prescription medications, as overprescribing opioids has become a national issue. According to 2012 CDC data, there are 96-143 opioid prescriptions per 100 people in North Carolina, compared to 52-71 prescriptions per 100 people in the lowest-prescribing states.
Mountain Area Health Education Center, Inc. (MAHEC) is working to prevent opioid misuse and overdose by educating patients and the larger community on safer alternatives to pain management. In addition to Asheville and Henderson at Blue Ridge Community Health Services, MAHEC's Integrated Chronic Pain Treatment and Training Project (ICPTTP) was implemented at Andrews Internal Medicine in rural Andrews, which serves rural Cherokee, Clay, Graham, and Macon counties.
MAHEC created the ICPTTP in order to stabilize and streamline chronic pain management in primary care clinics. Multidisciplinary care teams provided medication management and behavioral health services as well as trained primary care providers (PCPs) in chronic pain management. Care teams educated patients and suggested alternative pain treatments such as physical therapy and acupuncture.
MAHEC partnered with Project Lazarus, which provides community outreach and education about opioid misuse. The ICPTTP received funding from a Centers for Medicare & Medicaid Services (CMS) Health Care Innovation Award (HCIA).
"Core providers" trained other PCPs on chronic pain protocols so that pain treatment is safer and standardized. Providers also learned how to identify and prevent opioid misuse, in part through drug screenings. Providers offered:
- Education about the potency of opioid medications and the potential for misuse
- Group medical visits, which provided social connection and support for patients
- Ways for patients to change their perception of pain (ways to endure pain and stay active)
- Screenings to identify behavioral health issues such as prior substance abuse or trauma
- Referrals for patients who would benefit from more intensive treatment for mental illness or substance abuse
The ICPTTP reached 376 patients from October 2012 to June 2015. According to the HCIA Disease-Specific Evaluation: Third Annual Report:
- The average daily morphine equivalent dose (MED) decreased significantly.
- 25% of participants stopped taking opioids altogether.
- Patients who began the program with a lower MED were more likely to stop taking opioids.
- Patients reported improved functionality and relief from mental health issues such as anxiety.
- One program site reported fewer emergency department visits (and lower healthcare costs), as patients visited the pain clinic instead.
Program coordinators found that there was a lack of understanding from patients and providers about the safety and efficacy of opioids.
Since Asheville is a larger community, patients at the Asheville site had easier access to services such as acupuncture, yoga, and behavioral health providers than patients at the rural sites.
The sites were still able to implement the program despite differences in staffing. For example, some program sites relied on nurse practitioners (NPs) while two sites implemented the project without NPs. Larger sites could hire a behavioral health provider, while the Andrews location wasn't able to fill this position. Without a behavioral health provider, PCPs at some sites were still able to implement the chronic pain protocols but said they would have appreciated having someone trained in substance abuse treatment.
To develop the program across western North Carolina, MAHEC staff members are developing a care process model and acting as consultants to other providers. Staff made seven site visits to other clinics and provided full-day consultations on protocols such as reduced dosage in prescriptions.
Elizabeth Flemming, MA, LPC, Planner
Mountain Area Health Education Center
Pharmacy and prescription drugs
Prescription drug abuse
August 2, 2017
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